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Microgravity exposure induces a cephalad fluid shift and an overall reduction in physical activity levels which can lead to cardiovascular deconditioning in the absence of countermeasures. Future spaceflight missions will expose crew to extended periods of microgravity among other stressors, the effects of which on cardiovascular health are not fully known. In this study, we determined cardiac responses to extended microgravity exposure using the rat hindlimb unloading (HU) model. We hypothesized that exposure to prolonged simulated microgravity and subsequent recovery would lead to increased oxidative damage and altered expression of genes involved in the oxidative response. To test this hypothesis, we examined hearts of male (three and nine months of age) and female (3 months of age) Long-Evans rats that underwent HU for various durations up to 90 days and reambulated up to 90 days post-HU. Results indicate sex-dependent changes in oxidative damage marker 8-hydroxydeoxyguanosine (8-OHdG) and antioxidant gene expression in left ventricular tissue. Three-month-old females displayed elevated 8-OHdG levels after 14 days of HU while age-matched males did not. In nine-month-old males, there were no differences in 8-OHdG levels between HU and normally loaded control males at any of the timepoints tested following HU. RNAseq analysis of left ventricular tissue from nine-month-old males after 14 days of HU revealed upregulation of pathways involved in pro-inflammatory signaling, immune cell activation and differential expression of genes associated with cardiovascular disease progression. Taken together, these findings provide a rationale for targeting antioxidant and immune pathways and that sex differences should be taken into account in the development of countermeasures to maintain cardiovascular health in space.

IntroductionPatients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement.MethodsData were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman et al.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods.ResultsWhen effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI.ConclusionsThere may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.

PurposeManagers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment.MethodsWe conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes.ResultsPerceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture.ConclusionsAligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.

BackgroundQuantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value.ObjectiveTo understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients.DesignA total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation.ParticipantsHigh-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites.ApproachWe used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects.Key resultsPatients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization.ConclusionsPatients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

IntroductionDuring the pandemic, many creative aging programs stopped being delivered in person, and practitioners turned to various virtual platforms to deliver content for older adults to maintain their cognitive, physical, and psychosocial well-being. Collaborators from a university-based music therapy program and a global music museum developed asynchronous virtual programs, one for wellness populations and another for memory care settings. Content was developed and delivered by the paper’s principal investigators in collaboration with the museum’s curatorial team and an upper division music therapy class composed of juniors and first-year graduate equivalency students (n = 21). The asynchronous program included museum gallery content and music therapy interventions of singing, movement, and/or instrument playing based on highlighted geographic regions. The purpose of the study was to explore older adults’ experiences when participating in the program.MethodsFifty-six older adults from three post-acute care facilities (two skilled nursing facilities and one assisted living center) served as participants. Older adult participants were categorized as cognitively healthy (n = 27) or those diagnosed with dementia (n = 29) and attended five music sessions over 8 weeks, ranging from 30 to 60 min in length. A within-subject repeated measures design was used to investigate the impact of the creative aging program on older adults’ psychosocial well-being and engagement behaviors. Psychosocial well-being for cognitively healthy older adults were measured with the Multicultural Quality of Life Index, Engagement in Meaningful Activity Survey, and the PROMIS Social Isolation Short Form-4a. Psychosocial well-being for older adults with memory loss was measured with the Quality of Life in Late-Stage Dementia tool.ResultsCognitively healthy older adults showed an increase in psychological/emotional wellness after participating in the program, while older adults with memory loss appeared less irritable and physically uncomfortable and seemed to enjoy interacting with others more. Surprisingly, the cognitively healthy older adults also showed an increase in social isolation between the start and end of the program, which may not be related to the intervention, but to the fact that all three sites had COVID outbreaks during the study and had to pause their group activities programming and residents were required to stay in their rooms. Additionally, the music interventions fostered engagement behaviors of interest (facial expression, posture), and response (body movement, eye contact, and musical interaction with the leaders in the videos) for both groups of older adults. Instrument interventions were most engaging for cognitively healthy older adults. Singing interventions were most engaging for older adults with dementia, whereas movement interventions were less engaging for older adults with dementia.DiscussionFindings suggest that creative aging virtual programs can be delivered in asynchronous settings to enhance older adults’ well-being and foster engagement. Additionally, virtual programming may be used to augment ongoing programming or used to reach older adults when distance is a factor to enhance older adults’ well-being.

ObjectiveMethodResultsConclusionsThis study investigated the relationship between processing speed impairment severity and performance on the Rey 15-Item Test (RFIT) and RFIT + Recognition.Cross-sectional data from 285 examinees (228 valid/57 invalid) referred for neuropsychological assessment who were administered the RFIT, Weschler Adult Intelligence Scale-Fourth Edition (WAIS-IV) Processing Speed Index (PSI), Brief Visuospatial Memory Test – Revised, Rey Auditory Verbal Learning Test, and three independent criterion PVTs were included. PSI bands were operationalized as Intact (≥85SS; n = 163), Reduced/Possibly Impaired (77-84SS; n = 36), or Impaired (≤76 SS; n = 29). Receiver operator characteristic (ROC) curve analyses tested the RFIT and RFIT + Recognition’s classification accuracy for detecting invalid performance for the overall sample and by PSI impairment status.Those with intact processing speed performed significantly better on the RFIT and RFIT + Recognition than those with reduced/possibly impaired and impaired processing speed. Though verbal/visual memory predicted RFIT scores independently, PSI contributed additional variance. ROC curves for RFIT and RFIT + Recognition were significant (AUC=.64-.84). Optimal cut-scores yielded modest sensitivity (30%-63%) and high specificity (89%-93%) among those with intact and reduced processing speed but yielded unacceptable accuracy in those with impaired speed (AUC=.59-.62).Although the RFIT and RFIT + Recognition demonstrated acceptable classification accuracy in those with intact processing speed, accuracy diminished with increasing speed impairment. This finding was more pronounced for RFIT + Recognition compared to the traditional RFIT. As such, the RFIT may have limited clinical utility in examinees with more significant processing speed deficits. [ABSTRACT FROM AUTHOR]

The pressure for more affordable housing has resulted in intensification of residential development and biodiversity loss. Using seven medium-density housing developments in three New Zealand cities, we explore the relationship between medium-density and greenspace quality. We also compare the sites pre- and post-development to determine the extent of loss of permeable space. In six developments for which we had pre and post-data, percentage loss ranged from 12% to 67%. The development with the highest housing density (82 units/ha) had very poor vegetation quality. However, there was no correlation between density and vegetation quality for those with less than 60 units/ha, indicating potential for improving the ecological value of permeable areas. Medium-density developments prioritising communal space had the highest provision of permeable space. We offer some recommendations on the application of biodiverse-sensitive design and planning principles to support biodiverse human living environments. [ABSTRACT FROM AUTHOR]

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

BackgroundPatient access to clinical information represents a means to improve the transparency and delivery of health care as well as interactions between patients and health care providers. We examine the movement toward augmenting patient access to clinical information using technology. Our analysis focuses on “Blue Button,” a tool that many health care organizations are implementing as part of their Web-based patient portals. ObjectiveWe present a framework for evaluating the effects that technology-assisted access to clinical information may have on stakeholder experiences, processes of care, and health outcomes. MethodsA case study of the United States Department of Veterans Affairs' (VA) efforts to make increasing amounts of clinical information available to patients through Blue Button. Drawing on established collaborative relationships with researchers, clinicians, and operational partners who are engaged in the VA’s ongoing implementation and evaluation efforts related to Blue Button, we assessed existing evidence and organizational practices through key informant interviews, review of documents and other available materials, and an environmental scan of published literature and the websites of other health care organizations. ResultsTechnology-assisted access to clinical information represents a significant advance for VA patients and marks a significant change for the VA as an organization. Evaluations of Blue Button should (1) consider both processes of care and outcomes, (2) clearly define constructs of focus, (3) examine influencing factors related to the patient population and clinical context, and (4) identify potential unintended consequences. ConclusionsThe proposed framework can serve as a roadmap to guide subsequent research and evaluation of technology-assisted patient access to clinical information. To that end, we offer a series of related recommendations.

BackgroundSearching for online information to interpret symptoms is an increasingly prevalent activity among patients, even among older adults. As older adults typically have complex health care needs, their risk of misinterpreting symptoms via online self-diagnosis may be greater. However, limited research has been conducted with older adults in the areas of symptom interpretation and human-computer interaction. ObjectiveThe intent of the study was to describe the processes that a sample of older adults may use to diagnose symptoms online as well as the processes that predict accurate diagnosis. MethodsWe conducted a series of “think-aloud” protocols with 79 adults aged 50 years or older. Participants received one of two vignettes that depicted symptoms of illness. Participants talked out loud about their thoughts and actions while attempting to diagnose the symptoms with and without the help of common Internet tools (Google and WebMD’s Symptom Checker). Think-aloud content was categorized using an adapted Q-sort and general inductive approach. We then compared the think-aloud content of participants who were accurate in their diagnosis with those who were not. ResultsNineteen descriptive codes were identified from the think-aloud content. The codes touched upon Web navigation, attempts to organize and evaluate online health information, and strategies to diagnose symptoms. Participants most frequently relied on a strategy where they reviewed and then rejected the online diagnoses if they contained additional symptoms than those that were depicted in the vignette. Finally, participants who were inaccurate in their diagnosis reported being confused by the diagnosis task, lacking confidence in their diagnosis, and using their past experiences with illness to guide diagnosis more frequently than those participants who accurately diagnosed the symptoms. ConclusionsOlder adult participants tended to rely on matching strategies to interpret symptoms, but many still utilized existing medical knowledge and previous illness experiences as a guide for diagnosis. Many participants also had difficulty navigating the Internet tools, which suggests an increased need for navigation aids in Web design. Furthermore, participants who were inaccurate in their diagnosis had more difficulty with the Internet tools and confusion with the task than those who were accurate. Future work in this area may want to utilize additional study design such as eye-tracking to further understand the coordination between Web navigation, online symptom information processing, and diagnostic strategies.